Treatment of Acute, Non-Traumatic Low Back Pain

Background

Acute, non-traumatic low back pain (LBP) is a common chief complaint and has been estimated to lead to more than 2.7 million ED visits annually nationwide. It affects a broad range of individuals and can be painful and debilitating long after an initial ED visit. Often times in clinical practice, evidence based decisions on medical management of acute lower back pain seem to be thrown out the window; rather medications are prescribed on a gestalt medicament do jour. NSAIDs, muscle relaxants, and opioids have all been used in isolation and in combination for treating acute LBP but trials investigating the efficacy of these medications combined have produced heterogeneous results.

Clinical Question

Does combining either muscle relaxants or opioids to a regimen of NSAIDs improve functional outcomes and pain in patients with acute LBP?

Intervention

Control

Naproxen as above plus placebo (PRN Q8).

Outcomes

(Primary): Improvement in RMDQ (tool used to measure LBP and functional impairment) between ED discharge and one week later. (Secondary): Actual RMDQ scores at 1-week and 3-month follow up, adverse events, as well as specific exploratory outcomes as specified below:
One week after discharge from ED:
• Participants’ worst back pain level in the previous 24 hours
• Frequency of analgesic use in the previous 24 hours
• Satisfaction with treatment
• Day in which participant returned to work
• Frequency of visits to any clinician

Limitations

Limited generalizability as patients were not asked about current NSAID use at time of enrollment

Compliance with regimen randomized to was low (though this mimics real life)

The authors do not discuss what medications the study participants were given in the ED prior to discharge

Author's Conclusions

“Among patients with acute, non-traumatic, non-radicular LBP presenting to an ED, adding cyclobenzaprine or oxycodone/acetaminophen to naproxen alone did not improve functional outcomes or pain at 7 days. These findings do not support the use of these additional medications in this setting.”

Our Conclusions

Naproxen monotherapy is sufficient for medical management of acute non-traumatic, non-radicular LBP. Adding cyclobenzaprine or oxycodone/APAP was not shown to have any benefit in pain or functional outcomes both short and long term. Patients may in fact have more adverse outcomes from adding these medications to the mix. Keep in mind the individual patient’s current medication regimen, as this study did not look at outcomes for patients already on NSAIDs at the time of enrollment.

Potential Impact To Current Practice

In the right patient this can be brought to clinical practice immediately, leading to less polypharmacy and less adverse medication effects.

Bottom Line

Addition of either cyclobenzaprine or oxycodone/APAP to naproxen did not improve pain or functional outcomes in patients with acute LBP.